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FOR-OFFICE USE: - APPLICATION FOR SANITAVON PERMIT (Complete in Triplicate) Permit No. ________________________ This Permit Expires 1 Year From Date issued Date Issued ___z4__7�r Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein . described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB •ADDRESS/LOCATION ___ - J }}�� --i----�---��-1�------�-=---�--I- �-/4c-tj-�-� ---�±D�i�-----CENSUS TRACT A4-2------- Owner's Name ------�`Ph-T-/T ��C 1�[-�f -L ----------------- -----------------Phone Address =F i-I----r~----H-i---w-/+-- ,f------------------ k- ----------- City - b�-E-- --��---�-� �--�----- Contractor's Name --- -U' /-- -- ----5� J`a .l_C �'E�1Y'-- -----SIS_ License # _ -�' �- - Phone ---- - ----- - --- •-4i-- Installation will serve. Residence Apartment House[] Commercial :❑Trailer Court Motel ❑Other Number of living units:----I------ Number of bedrooms _______Garbage Grinder ------------ Lot Size -s-A Water Supply: Public System and name ------------------------------------ __-.__-________________Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam :❑ Hardpan ❑ Adobe'❑ Fill Material ____________ ifyes,type --------___________ (Plot plan, showing size of lot, location of system in. relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage,pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ 7 Size-------------------•-------------------------— Liquid Depth -------------------------- ~ Capacity -------------------- Type -------------------- Material------------------ No. Compartments Distance to nearest: Well .. -------------------------Foundation ---------------------- Prop. Line -------.- __-__- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------____--- Total Length 'D' Box --- Type Filter Material ____________________Depth Filter Material ----------------- ---------------- DIstance _______--__._ ---------------- Distance to nearest: Well --- ------------------- Foundation - Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------_--- ----------------- Rock Filled Yes ❑ No Water Table Depth -----------------------------1------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation .-------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------.------------------------------------ Date ---------------------------------- Septic ------------ --------------------Septic Tank (Specify Requirements) ------------ ----------- - !I�� Dispos Field (Specify Requirements) art"_ _------ --- -------------------------------------- - --- ----- [Draw existing nd required ad--------------------------------------------------------------- ----------------- (Draw on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- --------------------------- Owner - ----- ----- By ----=/�� TitleOY1- r (if other tho owner] r ------ -- ------------ FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY -- -------------------------------------------------------------------------------- DATE __ _"_I-D ------ BUILDING PERMIT ISSUED ----- . - ----- DATE --------------------------------------------------- - ADDITIONAL COMMENTS - ------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- -------------------- ------------------------------------------- -------------------------------'--'- -----_- -------________ --------------------------------------- - Final Inspection by --------------------------------- ---------------------- -Date -------.�ll'7 ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM